One explanation I haven’t seen: doctor forgot. I’ve definitely done that, particularly with patients where the majority is the visit is counseling on various things and it’s only after going to type up my note after the visit that I realize I didn’t do a physical exam.
Otherwise agree with the health care providers here. Auscultation is a basic skill, even if we are far from what used to be able to be done (look up how Wenckebach elucidated what was going on with Mobitz 1 AV block) and should be part of almost any visit.
This makes me so angry. Doctors have completely lost the art of the physical exam. I used to teach the physical exam to second year students. So much gets missed because doctors don’t actually examine their patients. I hear about patients seeing an orthopedist with back pain and not being examined at all. I can list so many “missed” diagnoses:
-The man with left leg weakness seen in the ER twice and told he had sciatica; a quick neurologic exam of his legs showed early Guillain-Barre which was able to be treated early enough to avoid severe disease
-The woman seen for “hip pain” in whom an abdominal exam showed an acute abdomen (found at surgery to be metastatic ovarian cancer)
-The countless, countless patients who “keep getting yeast infections but it goes away in 3-4 days with treatment” who have never actually been examined and who actually have herpes
-The patient I saw last week who was seen in the ER with back pain and given pain medications, when a ten second look at the site of the pain showed it was shingles
I pretty much listen to every patient’s heart and lungs unless they come in for a very specific complaints like an ingrown toenail. I’ve picked up atrial fibrillation multiple times. (I usually double check blood pressures first and I often pick it up then). I’ve certainly picked up pneumonias. I’ve diagnosed subclavian stenosis from noticing that the pulses in the wrists were unequal. One patient of mine is terrified of her yearly physical exam (one year I found a breast mass that turned out to be breast cancer; the next year I felt a thyroid mass that turned out to be thyroid cancer).
This is all to say that the physical exam is a useful tool. Yes, we have additional exams that can yield more detailed information but you can learn so much just by taking the time to examine the patient and it is a shame that doctors are not reimbursed for exams.
In residency, I had a colleague who trained in South Africa where they really learn to examine patients and we used to have competitions to, for example, see how many physical findings of aortic insufficiency we could name (just for starters-Corrigan’s pulse, Quincke’s pulse, Duroziez’s sign, Landolfi’s sign, de Musset’s sign, Muller’s sign). He won by a landslide every time. I used to challenge the medical students to name 20 different findings on physical exam that indicate liver disease. I miss the times when we could make diagnoses and then confirm it with the appropriate tests rather than just throwing every test at every patient.
Preach it! So damn true. I was taught that you could see a lot just by looking.
They challenged us in med school by having us examine a patient with dextrocardia. Out of the 120 of us, 2 figured out the diagnosis by physical exam alone. I was NOT one of those two.
I would argue naming physical exam findings is a far cry from actually recognizing them when you come across them. For instance, differentiating an Austin Flint murmur from the aortic regurgitation murmur or even from a regular mitral stenosis murmur. And the number of “atrial fibrillation” referrals I’ve received which were frequent PACs/PVCs or AT are too numerous to count. Having said that I do agree the physical exam is very important but I would be very hesitant to diagnose anything significant based solely on that. For the non medical but medically minded people reading, the Rational Clinical Exam series from JAMA is an excellent resource for looking into what findings are actually useful and which are just “truth” passed down from attending to trainee year after year.
You know this, but many people reading this won’t: Repeated yeast infections, regardless of where, are also a symptom of uncontrolled diabetes.
I had a heart murmur detected with a stethoscope during a routine exam. It was a damaged valve that required surgery to repair.
I almost lost the use of my leg because a specialist missed something simple. I figured it out using an oximeter on a toe. My leg had an arterial blood clot the entire length of it.
I absolutely agree that being able to name findings is useless. We did it as an intellectual exercise but knowing that these findings exist gives you something to look for. Also wrt atrial fibrillation, hearing an irregular heartbeat is just the first step. I can then do an EKG and refer to a cardiologist if necessary. I do not dispute that sometimes you hear an irregular beat and an EKG shows PACs or PVCs but if you don’t listen you will never pick up anything. (Incidentally, I am known for listening to the heart and asking my patients “Have you always had that irregular heartbeat/murmur/extra sound” and being told “You ask that every visit.” Once I have documented that the patient has frequent PACs then I don’t worry if I hear a few irregular beats. In addition, I am not above curbsiding a cardiologist to ask if an EKG shows an arrhythmia that they need to evaluate further in order to avoid sending the patient for an unnecessary consult. My point is simply that you definitely will miss things if you don’t examine a patient and you will definitely find things that change the plan of care if you do.
Of course! There is no excuse for a missed physical exam unless you are a psychiatrist, and even then there are things they will note (affect, movements, etc) that are components of a physical exam. I just wanted to expound on the place in the diagnostic work up of the exam. My patient with tearing acute pain in his chest radiating to his back and brachial femoral pulse delay didn’t go to the OR emergently based on that but it sure moved him up the line for a CT scan that showed the ascending aorta dissection. It is a dying art in a sense but it’s also dying because it’s been mostly supplanted by better testing. We no longer have to rely on a heart murmur and guess there’s a valve problem; now we can do an echo and actually quantify the degree of regurgitation or stenosis or obstruction or whatever.
I doubt that anybody will actually note a brachial pulse delay.The patient you discuss will not get a brachial pulse checked before the CT and frankly, I agree that someone with tearing chest pain deserves an emergent CT.